Health inspection·April 20, 2023

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, review of medical record and review of Policy for Central Line Dressing Changes revealed the facility failed to ensure Resident #27's central line dressing was changed as ordered. This affected one resident (Resident #27) out of one resident reviewed in a sample of two residents, (Resident #27 and #241) with intravenous access. The facility census was 88. Residents Affected - Few Findings included: Review of medical record for Resident #27 revealed an admission date of 09/09/22 and his diagnoses included infection and inflammatory reaction due to internal right hip prosthesis, acute and chronic respiratory failure with hypoxia, diabetes, and hypertension. Review of quarterly Minimum Data Set (Minimum Data Set (MDS)) dated 03/29/23 revealed Resident #27 was cognitively intact. He required extensive assistance of one person with bed mobility and extensive assistance of two people with transfers. He was unable to ambulate. He received intravenous medications. Review of undated care plan revealed Resident #27 was on intravenous medications for septic joint infection. Intervention included change dressing to [NAME] (a type of central line usually used to administer medications intravenously through the venous system) catheter twice a week on Tuesdays and Fridays, check dressing at site daily, and monitor for any side effects of intravenous antibiotic use. Review of April 2023 Treatment Administration Record (TAR) revealed Resident #27 had an order to change his midline (A vascular access device placed into a peripheral vein in the upper arm) dressing and caps every week (every Tuesday on night shift) per protocol. The TAR revealed Resident #27's midline dressing change was to be changed on 04/11/23 but that the documentation for this date on the TAR was blank. Review of physician order dated 04/11/23 revealed Resident #27 was to have his midline dressing and caps changed every week. Observation on 04/18/23 at 8:52 A.M. revealed Resident #27 had a midline intravenous catheter to his right arm. The central line dressing to the midline catheter was noted to be partially coming off as it was peeling from the bottom and the dressing was dated 04/05/23 (13 days since last changed). Interview on 04/18/23 at 8:52 A.M. with Resident #27 revealed he was unsure when the last time they had changed his central line dressing and/ or how often it was to be changed. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365937 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365937 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohman Family Living at Briar 15950 Pierce St Middlefield, OH 44062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)